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Paediatric Injury Scoring and Trauma Registry 165

An illustration of how to calculate ISS is shown in Table 26.2. Table 26.2: Sample calculation of ISS.
The ISS score for the example in Table 26.2 is 50, which is a very
Square of
severe injury requiring the patient to be admitted to a hospital for Body region Description of injury AIS score top three AIS
trauma care. Patients with ISS scores ≥15 should be cared for in a scores
hospital or trauma centre with adequate resources and experience in Head and neck Cerebral contusion 3 9
trauma care.
The ISS calculations include spine injuries in the corresponding Face Minor injury 1 16
three ISS body regions: cervical in ISS head or neck, thoracic in ISS
chest, and lumbar in ISS abdominal or pelvic contents. Chest Unilateral flail chest 4 25
New and Modified ISS Pneumothorax 3
In 1997, a simple modification of ISS was formulated and referred to Abdomen Minor contusion of bowel 2
10
as the New ISS (NISS). It is defined as the sum of the squares of the
Completely shattered 5
AIS of each of the patient’s most severe AIS injuries irrespective of the spleen
body region in which they occur. 3,5,10 The NISS is reported to predict
3
survival better than the ISS by better predicting mortality in the more Extremity Femoral shaft fracture 3
11
severely injured patients, and it is simpler to calculate. Skin Minor injury 1
There is also a Modified ISS (MISS), specifically intended for
paediatric trauma cases. This modification was made to account for Injury Severity Score = 50
5
the predominance of head injuries in paediatric trauma patients. In the
MISS, the number of body regions is reduced to four: face/neck, chest,
5
abdomen/pelvic contents, and extremities/pelvis. The MISS uses the Table 26.3: The Modified Injury Severity Score (MISS).
Glasgow Coma Scale (GCS; see next section) value categories (Table
Glasgow Coma Scale Neurologic score
26.3) to determine the AIS head region scores and also assigns injuries
of the skin/general category within any of the four body regions listed 15 1: Minor
above. The MISS is calculated by summing the squared AIS values 13–14 2: Moderate
for the three most severely injured body regions. Several studies have
9–12 3: Severe, not life-threatening
validated the MISS in paediatric trauma and have shown it to accurately
12
identify patients at high risk for mortality and long-term disability. In 5–8 4: Severe, survival probable
spite of this, the MISS is not widely used because improvements have 3–4 5: Critical, survival uncertain
been made in the more recent versions of the AIS and ISS.
Anatomical Profile
The AP addresses some of the shortcomings of the ISS. It uses the AIS
descriptors of anatomic injury, but includes only four body regions: A = Table 26.4: Sample calculation of AP.
head/brain and spinal cord; B = thorax/neck; C = all other serious inju-
1,2
ries other than in the areas of A and B; and D = all nonserious injuries. Component Injury AIS score
Injuries with an AIS value >2, which are defined as serious, are scored for 1. Head/brain 5
the first three categories above. All minor injuries, defined as AIS scores A 2. Spinal cord 3
1
2
of ≤2, are classified as nonserious, regardless of their anatomic location.
The total AP score is the sum of the square roots of the sum of the squares B 1. Thorax 4
of the AIS for all individual injuries within a region (Table 26.4). This 2. Front of neck 3
1,2
allows the second and third injuries occurring within a given region to be 1. Liver laceration 4
considered in the final AP score, preventing the loss of information that C
occurs with the ISS. AP is most useful in an inpatient setting and has 2. Above-knee amputation 4
1
neither been widely used nor validated for paediatric trauma. D 1. All other injuries 1
1,2
Physiologic Injury Scoring Systems AP = ∑[√(5 +3 ) + √(4 + 3 ) + √4 +4 )] = ∑[√34 +√25 + √32] = 5.8 +5.0 + 5.7 = 16.5
2
2
2
2
2
2
Physiologic scoring systems attempt to measure multiorgan system The AP score =16.5
derangements following trauma. These physiologic scoring systems are
strong predictors of mortality and tend to focus on abnormalities of many
systems, including respiratory, haematologic, and neurologic. They are es including eye opening, motor responses, and verbal responses. The
especially valuable in triaging patients; hence, they are also referred GCS was first introduced in 1970. As shown in Table 26.5, the GCS
to as triage scoring systems. They are also valuable in providing data has been modified for use in infants and children and is referred to as
on functional outcomes. Examples of physiologic scoring systems are: the paediatric GCS. 5,13 The GCS is scored between 3 and 15, with the
the Glasgow Coma Scale (GCS); the Trauma Score (TS) and Revised worst score being 3 (indicating deep coma or death) and the best being
Trauma Score (RTS); Circulation, Respiration, Abdominal/Thoracic, 15 (indicating no neurologic deficit).
Motor and Speech Scale (CRAMS); and the Acute Physiology and The GCS is easy to use even in the prehospital setting, and can be
Chronic Health Evaluation (APACHE) scale. These are mainly used applied to the patient on multiple occasions throughout the postinjury
2
4
for prehospital triage of patients, with the exception of the APACHE period, following changes in level of consciousness over time. It has
scale, which is widely used in the intensive care unit (ICU) for assess- been found that the trend of multiple measures of GCS taken over
ing the severity of illness in acutely ill patients.
time is a more sensitive predictor of outcome than a single, absolute
Glasgow Coma Scale value of the GCS. The ease of use of GCS makes it attractive to
The GCS was developed as a means of assessing a patient’s level of clinicians in the field, in the emergency department for triage, and by
consciousness by assigning coded values for three behavioural respons- emergency physicians to document and communicate serial neurological